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Table 1 Temporal sequence of resuscitation events

From: Successful resuscitation of an elderly man with deep accidental hypothermia using portable extracorporeal circulation in the emergency department: a case report

Time

Patient status/Event

0715 – 0800 Pre-Hospital

Patient was unresponsive with absent pedal pulses but palpable radial pulses with delayed capillary refill. A 20 ga. IV line was established and patient was intubated. Vitals were bradycardia with HR 33/minute, BP of 86/51 mm Hg, and tympanic temperature of 25.5°C. Warm IV fluids were given and hot packs were applied to groins and axillae.

0800 Arrival to Hospital

Patient arrived to medical center with no palpable pulses. Monitor showed PEA with bradycardia of HR 31/minute. CPR was started. Atropine 0.5 mg IV was administered followed by 1 mg epinephrine IV. Tympanic temperature was 25.5°C.

0808

Patient converted to sinus rhythm with HR 66/minute, but shortly thereafter went into pulseless V-tach. An amiodarone bolus of 300 mg was administered IV followed by 1 gm calcium IV. The patient went into V-fib and CPR resumed.

0812

Central line placed along with an additional 16 ga. IV line. Warm IV fluids were administered.

0815 – 0825

A gastric tube and bilateral chest tubes were placed. Warm gastric and pleural irrigation was initiated.

0845

Patient remained in V-fib arrest receiving CPR. Temperature remained 25.6°C despite conventional warming therapies of warm fluid instillation (IV, gastric, intrapleural), warm humidified oxygen, and warming blankets. The decision was made for extracorporeal rewarming and resuscitation.

0845 – 0900

Patient was heparinized, CPS unit was assembled and primed, and arterial and venous cannulas were placed for fem-fem CPS.

0900

Patient was placed on fem-fem CPS and CPR was stopped. Patient remained in V-fib arrest. CPS unit temperature monitoring confirmed patient blood temperature of 25.5°C.

0900 – 1100

Patient was slowly rewarmed on CPS and electrolytes and acid base status were normalized. Patient remained in V-fib arrest. An arterial line was placed which showed a systolic BP of 55 mm Hg. Vasopressin was started.

1102

Patient temperature was 34.9°C and defibrillation was attempted. Initial defibrillation at 200 J converted rhythm from V-fib to V-tach, and a subsequent defibrillation of 300 J converted rhythm to SVT. A bolus of 300 mg amiodarone IV was administered followed by 1 gm calcium chloride IV.

1112

Patient reverted into V-tach. Two defibrillation attempts of 360 J converted rhythm into sinus tachycardia and HR 102/minute. Patient temperature was 35.5°C.

1200

Patient temperature was 37°C after 180 minutes of extracorporeal rewarming.

1230

Patient was transported to OR for weaning of CPS and decannulation under direct vision. Patient was in sinus rhythm, HR 87/minute.

1330

Patient was successfully weaned from CPS after 270 minutes of bypass with BP 140/60, HR 80/minute, in sinus rhythm, and temperature of 37°C.

  1. IV: intravenous; HR: Heart Rate; BP: Blood Pressure; J: joules; PEA: Pulseless Electrical Activity; CPR: Cardiopulmonary Resuscitation; V-Tach: Ventricular Tachycardia; V-Fib: Ventricular fibrillation; A-V: Arterio-Venous; CPS: Cardiopulmonary Support; Fem: femoral; SVT: Supraventricular Tachycardia